Commercial General Liability Application For Logging Contractors Page 2
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210. Are there any known contractual obligations where the Applicant has to provide insurance on behalf of
another or hold another harmless?
Yes
No
If yes, please list all lease agreements, railway siding agreements, etc., and provide copies of these
agreements: ____________________________________________________________________________
11. Are there any additional Insured’s to be added to the policy?
Yes
No
If yes, please list and state purpose: __________________________________________________________
Name
In Connection With
12. Give details of last five (5) years losses. Show all amounts “net” of deductible, and include reserves for
unsettled losses:
Date of Loss
Cause of Loss
Amount Paid
Amount Outstanding
13. a) Area/Location of operations:
Crown Land
Privately Owned Land
b) Any structural occupancies near by?
Yes
No
If yes, distance from occupancy to logging operations: __________________________________________
Details of Occupancy: ____________________________________________________________________
14. a) Do you currently carry liability insurance?
Yes
No
b) Please advise current liability carrier and expiry date: _________________________________________
c) Please advise current limits carried: _______________________________________________________
d) Has any Insurer cancelled or refused to renew?
Yes
No
If yes, provide details: ____________________________________________________________________
15. Limit of liability requested in this application: _________________________________________________
_________________________________________
__________________________________________
Date
Completed By
_________________________________________
__________________________________________
Date
Applicant’s Signature
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